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The Kaiser Permanente doctor who examined Harun Antwine had
worked at
least 10 hours that day, seeing 25 patients in his office and 15 more
that
evening at the HMO's Fontana urgent care center.

The swamped physician didn't spot Antwine's serious bacterial
infection,
and the 29-year-old patient left urgent care without antibiotics,
Antwine's
family lawyer says. The father of three young children died two days
later.

"It was a classic case of failing to treat a patient [who]
really needed
it," said lawyer Gregory Patton, who won an $848,000 arbitration award
from Kaiser stemming from Antwine's 1998 death. "Their doctors are
really,
really overworked."

In justifying a $1.1-million fine against Kaiser, state
regulators cited
three patient deaths and said the cases demonstrated a pattern of
problems
in emergency care that has put the HMO's 6 million California members
at
risk.

Similar problems showed up in at least nine other cases since
1995--including
Antwine's--in which arbitrators found Kaiser liable for patient
injuries
or deaths.

Although the number of arbitration awards is small, and Kaiser
calls
the cases anomalies, critics say they illustrate the same dangers
identified
by state officials: not enough staff and overcrowded facilities.

Kaiser, the state's largest HMO, denies that it has systemic
problems
and argues that the state's HMO czar, Daniel Zingale, has overstepped
his
authority. It is challenging the fine, which was imposed in 2000 and
was
increased last year.

Moreover, Kaiser said the arbitration awards reviewed by The
Times should
not be considered a pattern, given the millions of patients who seek
care
through the HMO.

"These cases are obviously things that everybody wants to pay
attention
to," Kaiser spokesman Jim Anderson said. "But to suggest anything other
than that they represent [nine] individual medical malpractice cases is
stretching a long way, we think."

Arbitration awards, though relatively rare, are among the few
public
avenues available for examining patient complaints against Kaiser.
Dissatisfied
Kaiser patients seeking damages must go through arbitration, because
the
HMO requires enrollees to waive their right to sue.

According to the nine arbitration summaries, Kaiser has been
ordered
to pay more than $3.5 million for lapses in emergency or urgent care
since
1995.

That amount represents only a fraction of what Kaiser has paid
out in
cases that were settled and sealed from the view of the public and HMO
regulators, patients' lawyers say. Kaiser has settled nearly half of
its
recent arbitration cases, records show.

The nine cases reviewed by The Times include those of:

• A 39-year-old diabetic woman who died after her chemical
imbalance
went undetected by an urgent care doctor in Lancaster.

• A 6-year-old boy who died in the hospital after the Kaiser
urgent
care center in Panorama City failed to diagnose a heart ailment.

• A 64-year-old man who died of an undiagnosed ruptured
abdominal aortic
aneurysm at the Woodland Hills urgent care center.

• A 41-year-old man who went to Kaiser's Panorama City
emergency room,
where his chest pain was attributed to yardwork. The man visited Kaiser
facilities twice more before dying five days later of a heart attack.

Anderson said the nine arbitration awards involved different
facilities,
different patient symptoms and different outcomes. He said Kaiser has
11
emergency rooms in Southern California that see 800,000 patients a year
and that many more people visit urgent care centers.

The arbitration cases also span a significant period of time,
Anderson
said. Though all were decided since 1995 and most involved incidents in
the last decade, one dates to 1987. Arbitration cases can take years to
resolve.

Kaiser argues that even if everyone does their best, patients
sometimes
die.

That, Kaiser claims, is what happened in the case of Antwine,
the 29-year-old
who died of a bacterial infection.

When the patient arrived at the urgent care center,
arbitration filings
say, he wasn't exhibiting typical symptoms of a strep bacterial
infection.
Even if he had been given antibiotics, the HMO said, Antwine would have
died.

Critics say such cases should not be viewed in isolation. In
fact, the
state findings and the arbitration claims are, in some instances,
remarkably
similar.

Two of the cases won in arbitration involved patients who died
of undiagnosed
abdominal aortic aneurysms, the problem also found by the state in its
investigation.

In their fine, state regulators cited the case of Wolfgang
Spunbarg,
a 72-year-old enrollee who went to the Woodland Hills emergency room in
April 2000 complaining of severe pain in his abdomen and testicles.

According to the hearing testimony of Spunbarg's wife, Edith,
she pleaded
with the ER receptionist to have someone examine her husband
immediately
but was told that the ER was too busy and that she would have to wait.

About 15 minutes after arriving, she burst into the
examination area
of the ER and demanded that a doctor see her husband. Moments later, he
fell unconscious; he died within two hours of an undiagnosed abdominal
aortic aneurysm.

According to filings in a separate arbitration case, Gery
Lichtig, 64,
had gone to the urgent care center at the same hospital 13 months
earlier,
complaining of serious abdominal and back pain. As in the Spunbarg
case,
Lichtig's wife, Temah, pleaded with the receptionist to call a
physician.

After being seen by a nurse, Lichtig waited 45 minutes,
retching in
pain, according to the arbitration filings.

On his way back from having X-rays taken, the documents state,
Lichtig
leaned back in his wheelchair and screamed, "The pain, the pain!" His
eyes
then rolled back, and he fell unconscious. He died less than three
hours
later, also of a ruptured aneurysm.

Temah Lichtig said the state's findings were like a horrible
echo of
her own experience with Kaiser.

"The state is so accurate in everything that they're saying,"
she said.
"They're just calling it like it is."

Kaiser is challenging the $1.1-million fine before an
administrative
law judge, claiming that Zingale does not have the authority to
regulate
care provided by its hospitals and doctors. Testimony resumes this
month
in Oakland.

Defending the fine, Zingale said the California Department of
Managed
Health Care found that Kaiser doctors and nurses failed "to communicate
. . . the seriousness of a patient's condition and the need for a rapid
response."

He said some of the claims raised in the arbitration cases
reviewed
by The Times seem "of a similar nature to what we're looking at." But
the
cases were not cited in support of the fine because they alleged
individual
instances of medical malpractice, not systemic problems.

Several patients' lawyers said they did not allege systemic
problems,
because winning individual malpractice cases does not require proof of
widespread flaws.

The plaintiffs' lawyers say Kaiser's problems are more
extensive--and
the real toll paid by the HMO is far higher--than the public record
suggests.
The awards obtained through arbitration reflect only those cases in
which
a verdict was reached, not those settled confidentially.

Kaiser declined to discuss the number of cases that it has
settled or
their amounts.

"There's systemic problems with everything they do," said
Bruce Levenson,
a Beverly Hills lawyer who represented the family of the diabetic woman
who died. "I think they give you as little care as they possibly can. .
. . They cut corners."

Anderson, however, said Kaiser is more likely than other HMOs
to be
targeted by arbitration complaints because it owns its hospitals and
works
primarily with one doctors group. As a result, patients associate
quality
of care with the HMO itself.

Kaiser is also more likely to face action related to the
quality of
patient care from state HMO regulators, as Zingale himself
acknowledges.

But some lawyers and family members who have won arbitration
awards
against Kaiser say they only wish its flaws had come to light sooner.

"I want to help bring this awareness to other people so Gery's
death
will not have been in vain," Temah Lichtig said. "This man did not have
to die."

Kaiser argues that he could not have been saved.

"People can do their very best and do everything right and do
superhuman
efforts, and the patient will still suffer a bad outcome," Anderson
said.
"That's just a sad fact of medical life."

Times researchers John Tyrrell and Scott Wilson contributed to
this
report.

Arbitration Awards

At least nine times since 1995, arbitrators have found Kaiser
Permanente
liable for lapses in care provided to patients at its emergency rooms
and
urgent care centers. Arbitration cases sometimes are decided well after
the alleged lapses occur.

1995

Arbitration award: $350,000

Claim: Kaiser should have hospitalized a 43-year-old woman
with asthma
when she went to the emergency room in Riverside in January 1993,
complaining
of fever, shortness of breath and other problems. Instead, the hospital
sent her home. She died the next day after returning to the emergency
room
with respiratory distress.

1996

Arbitration award: $325,000

Claim: Kaiser failed to diagnose a heart problem in a
41-year-old gas
station owner who went to the emergency room in Panorama City with
chest
pain, sweating and arm numbness in 1994. Doctor attributed muscle pain
to yardwork and sent man home. He returned to Kaiser twice before he
died
June 10 of a heart attack.

1997

Arbitration award: $500,000

Claim: Kaiser failed to prescribe antibiotics to a 4-year-old
child
who went to the Anaheim emergency room with fever, nausea and joint
pain
in February 1987. The child developed bacterial spinal meningitis and
became
deaf as a result of the condition.

Arbitration award: $257,190

Claim: Kaiser Bellflower emergency room failed to hospitalize
a 48-year-old
woman who complained of chest pain, low blood pressure and anemia in
1993.
She died four days later of a ruptured abdominal aortic aneurysm.

1999

Arbitration award: $848,000

Claim: Kaiser urgent care center in Fontana failed to treat a
bacterial
infection in a 29-year-old food service manager in March 1998.
Physician
discharged him despite high fever and inability to walk. He died of
complications
from the infection.

Arbitration award: $250,000

Claim: Kaiser urgent care center in Mission Viejo failed to
remove glass
from the knee of a 9-year-old girl who struck a glass cabinet door in
May
1995. Glass was removed surgically more than two years later, causing
cartilage
damage.

Arbitration award: $407,000

Claim: Kaiser urgent care center in Panorama City failed to
diagnose
a viral heart ailment in a 6-year-old boy who sought medical care in
May
1994. Although he was admitted to a hospital, the boy died several
hours
later.

2001

Arbitration award: $375,000

Claim: Kaiser urgent care center in Lancaster failed to
diagnose a chemical
imbalance and dehydration in a 39-year-old diabetic woman who sought
help
in January 1999. She was discharged and died hours later.

Arbitration award: $354,500

Claim: Kaiser urgent care center in Woodland Hills did not
diagnose
a ruptured abdominal aortic aneurysm in a 64-year-old man who died
while
seeking care in March 1999.